Deserted by Doctors, India's Poor Turn to Quacks

By CELIA W. DUGGER

Published: March 25, 2004

BHOMATAWARA, India—
The sturdy little public clinic in this poor, sickly village was locked up one recent afternoon, but that is nothing remarkable. Rampant absenteeism among government doctors and nurses is an open secret across India and much of the developing world, and they virtually never get in trouble for not showing up.

''Sometimes the nurse is here, sometime she's not,'' said Nagji Lal Pandore, a skinny old man in a saffron turban. ''Sometimes she has medicines, sometimes she doesn't. Why take a chance?''

So, like many people here, his family has turned to amateur private ''doctors'' who have regular hours and plentiful medications to sell.

His daughter-in-law Shanti Bai, 30, went to such a doctor for a fever six months ago. He gave her an injection. The next day, she was dead and her children motherless.

Villagers blamed the doctor and he fled, but the heartache remains. Mr. Pandore and his wife have broken the news to their 5-year-old grandson, but they are still telling their 3-year-old granddaughter that her mother is away on a trip. ''She cries and cries and asks, 'Where is my mother?' '' he said.

India has a vast primary health care system to serve its billion people, with clinics for every 3,000 to 5,000. But the system is often just a skeleton. New studies have documented the startling, damaging dimensions of chronic absenteeism -- and not just in India.

Researchers for the World Bank discovered through large national surveys that medical personnel were absent from their public posts 35 to 40 percent of the time in India, Bangladesh, Indonesia and Uganda, and about a quarter of the time in Peru.

Researchers from the Massachusetts Institute of Technology and Princeton, in a detailed survey of 100 villages here in Rajasthan, in north India, found a no-show rate of 44 percent. When combined with absences for meetings and other work-related reasons, these vital clinics were closed more than half the time.

As the United Nations leads a global effort to prevent millions of deaths from AIDS, tuberculosis, malaria and a range of childhood illnesses, the fissures in public health systems are emerging as a main obstacle.

There is an increasingly heated debate among experts about whether multibillion-dollar infusions of foreign aid or politically sensitive domestic reforms are more central to repairing public health systems.

What is starkly clear in India, home to more poor people than any other country, is that the health system is both starved for resources and desperately in need of reform.

Here in the villages outside Udaipur, one of India's loveliest tourist destinations, rough-hewn clinics for the rural poor generally have no phones, no vehicles, no running water. Most have no electricity. On a recent day, they lacked syrup-based medicines to treat young children for fevers, vomiting, coughs and respiratory infections. Some nurses said they had run out of the basic pills provided by the government.

India's public health spending is among the lowest in the world -- $4 a person per year, less than 1 percent of its gross domestic product, the United Nations Development Program says. The United States spends about $2,000 a person, or almost 6 percent of gross domestic product.

But India's experience also shows that more money alone is not the answer. India sharply increased its health spending in the 1990's, but most went for new hiring and for pay raises to those doctors and nurses who are not showing up for work, according to a World Bank analysis.

The dramatic progress in reducing infant mortality in the 1980's slowed in the 1990's, while mortality for children under 5 did not improve at all.

The economists coordinating the research here -- Professors Abhijit Banerjee and Esther Duflo, co-founders of the Poverty Action Lab at M.I.T., and Angus Deaton at Princeton -- will work with 120 villages and 100 clinics.

They will add a nurse to each clinic and monitor attendance through a punch clock or dated digital photographs. They also will try chlorinating contaminated well water, fortifying flour with iron to fight anemia and paying parents to have their children immunized.

They will try each strategy in half the villages or clinics, then compare the health of people in villages that got the help with those that did not.

What is here now is not working very well. The survey and accompanying blood tests of villagers found that most people were scrawny and weakened by anemia. Three out of 10 said they had trouble mustering the strength to walk a couple of miles or draw water from a well.

But when asked to rate their health on a scale of 1 to 10, most placed themselves in the middle.

''Their health is awful and their health care even worse,'' said Professor Deaton, an expert on Indian poverty. ''They know they're really poor, but they don't know they're really sick. One of the things that drives some of us to despair is that this isn't a political issue among them.''

In Bhomatawara, where the young mother, Shanti Bai, died, villagers say the government nurse is often not at the clinic. On three visits to the village, she was never there.